OR| The Oregon Department of Consumer and Business Services‘ Bulletin No. DFR 2025-4 provides updated guidance for health insurers regarding coverage of gender-affirming treatment under new state law and rules effective January 1, 2025. The bulletin clarifies that health benefit plans must cover all medically necessary gender-affirming treatments as determined by providers, following the World Professional Association for Transgender Health’s Standards of Care Version 8 (WPATH-8) as a minimum standard, and prohibits categorical cosmetic exclusions. It also addresses network adequacy, requiring insurers to ensure sufficient access to gender-affirming providers or, if not possible, to cover out-of-network services at in-network cost-sharing levels. The bulletin mandates that providers reviewing adverse benefit determinations complete specialized training and affirms that detransition services are covered when medically necessary. The department will monitor compliance and provide further network adequacy standards in the future.
Key Points:
- Health benefit plans must cover all medically necessary gender-affirming treatments according to WPATH-8 standards, prohibiting blanket cosmetic exclusions.
- Insurers must ensure adequate provider networks or allow out-of-network access at no greater cost to the enrollee if in-network options are unavailable or delayed.
- Providers reviewing denials of gender-affirming care must complete the WPATH SOC-8 training or an equivalent, with compliance expected by September 1, 2025.
- Medically necessary detransition services are covered, and enrollees may appeal adverse determinations through the external review process.